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Iran Specialty Board - Cardiology study materials
Iran Specialty Board - Cardiology study resources

Iran Specialty Board - Cardiology: Heart Failure and Cardiomyopathies

Iran Specialty Board - Cardiology · Work through your exam, one topic at a time.

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Heart Failure and Cardiomyopathies

Items in this domain test phenotype classification by ejection fraction, the four-pillar drug regimen, device indications tied to LVEF and QRS morphology, and recognition of infiltrative and inherited cardiomyopathies that imitate common heart failure.

Classification and the four pillars

  • HFrEF: LVEF 40% or less. HFmrEF: 41-49%. HFpEF: 50% or more with structural or diastolic evidence.
  • Mortality-reducing pillars in HFrEF: ARNI (or ACE inhibitor/ARB), an evidence-based beta-blocker (bisoprolol, carvedilol, metoprolol succinate, nebivolol), an MRA, and an SGLT2 inhibitor.
  • Add-ons: ivabradine when sinus rhythm exceeds 70 beats per minute on maximal beta-blockade; hydralazine plus nitrate in self-identified Black patients; vericiguat after worsening heart failure; digoxin for symptom control.
  • ARNI requires a 36-hour washout after an ACE inhibitor because of angioedema risk.

Devices

  • Primary-prevention ICD: LVEF 35% or less after at least 3 months of optimal therapy, NYHA II-III, survival beyond 1 year.
  • CRT: LVEF 35% or less, sinus rhythm, LBBB with QRS 150 ms or more (Class I); LBBB with QRS 130-149 ms is IIa.

Cardiomyopathy clues

  • HCM: unexplained septal thickness 15 mm or more, systolic anterior motion of the mitral leaflet, dynamic gradient; beta-blocker first, avoid vasodilators and volume depletion, screen first-degree relatives.
  • Cardiac amyloidosis: low-flow low-gradient aortic stenosis physiology, apical-sparing longitudinal strain, discordance between ECG voltage and wall thickness; confirm with bone scintigraphy after excluding monoclonal protein.
  • ARVC: T inversion in V1-V3, epsilon waves, ventricular arrhythmia with LBBB morphology and superior axis from the right ventricle.

Worked example

A 62-year-old with NYHA III symptoms, LVEF 30%, sinus rhythm, QRS 160 ms with LBBB, and eGFR 50 starts ARNI, bisoprolol, an MRA (potassium 4.2), and dapagliflozin, and is referred for CRT-D after three months of tolerated therapy.

Traps

  • Never initiate a beta-blocker during acute pulmonary oedema.
  • Do not start an MRA when potassium exceeds 5.0 mmol/L or eGFR is very low.
  • Do not label HFpEF without excluding amyloidosis and constrictive physiology.